Lesions of the oral mucosa in lymphoma patients receiving cytostatic drugs

The impact of the oral cavity in febrile neutropenia and infectious complications in patients treated with myelosuppressive chemotherapy

Febrile neutropenia (FN) is an inflammatory response causing fever that may develop during cancer therapy-induced neutropenia. FN may herald life-threatening infectious complications and should therefore be considered a medical emergency. Patients presenting with FN are routinely subjected to careful history taking and physical examination including X-rays and microbiological evaluations. Nevertheless, an infection is documented clinically in only 20-30% of cases, whereas a causative microbial pathogen is not identified in over 70% of FN cases. The oral cavity is generally only visually inspected. Although it is recognized that ulcerative oral mucositis may be involved in the development of FN, the contribution of infections of the periodontium, the dentition, and salivary glands may be underestimated. These infections can be easily overlooked, as symptoms and signs of inflammation may be limited or absent during neutropenia. This narrative review is aimed to inform the clinician on the potential role of the oral cavity as a potential source in the development of FN. Areas for future research directed to advancing optimal management strategies are discussed.

A systematic review of oral fungal infections in patients receiving cancer therapy

PURPOSE

The aims of this systematic review were to determine, in patients receiving cancer therapy, the prevalence of clinical oral fungal infection and fungal colonization, to determine the impact on quality of life and cost of care, and to review current management strategies for oral fungal infections.

METHODS

Thirty-nine articles that met the inclusion/exclusion criteria were independently reviewed by two calibrated reviewers, each using a standard form. Information was extracted on a number of variables, including study design, study population, sample size, interventions, blinding, outcome measures, methods, results, and conclusions for each article. Areas of discrepancy between the two reviews were resolved by consensus. Studies were weighted as to the quality of the study design, and recommendations were based on the relative strength of each paper. Statistical analyses were performed to determine the weighted prevalence of clinical oral fungal infection and fungal colonization.

RESULTS

For all cancer treatments, the weighted prevalence of clinical oral fungal infection was found to be 7.5% pre-treatment, 39.1% during treatment, and 32.6% after the end of cancer therapy. Head and neck radiotherapy and chemotherapy were each independently associated with a significantly increased risk for oral fungal infection. For all cancer treatments, the prevalence of oral colonization with fungal organisms was 48.2% before treatment, 72.2% during treatment, and 70.1% after treatment. The prophylactic use of fluconazole during cancer therapy resulted in a prevalence of clinical fungal infection of 1.9%. No information specific to oral fungal infections was found on quality of life or cost of care.

CONCLUSIONS

There is an increased risk of clinically significant oral fungal infection during cancer therapy. Systemic antifungals are effective in the prevention of clinical oral fungal infection in patients receiving cancer therapy. Currently available topical antifungal agents are less efficacious, suggesting a need for better topical agents.

Candida albicans Csy1p is a nutrient sensor important for activation of amino acid uptake and hyphal morphogenesis

Candida albicans is an important human pathogen that displays a remarkable ability to detect changes in its environment and to respond appropriately by changing its cell morphology and physiology. Serum- and amino acid-based media are known to induce filamentous growth in this organism. However, the mechanism by which amino acids induce filamentation is not yet known. Here, we describe the identification and characterization of the primary amino acid sensor of C. albicans, Csy1. We show that Csy1p plays an important role in amino acid sensing and filamentation. Loss of Csy1p results in a lack of amino acid-mediated activation of amino acid transport and a lack of induction of transcription of specific amino acid permease genes. Furthermore, a csy1Delta/csy1Delta strain, lacking Csy1p, is defective in filamentation and displays altered colony morphology in serum- and amino acid-based media. These data provide the first evidence that C. albicans utilizes the amino acid sensor Csy1p to probe its environment, coordinate its nutritional requirements, and determine its morphological state.

Anaesthetic implications of anticancer chemotherapy

In anaesthetic practice we deal with cancer patients who are scheduled for operations on tumours or other manifestations of malignant disease. Those patients are often debilitated and have significant weight loss accompanied with hypoproteinaemia, anaemia and coagulation disorders. Oncological patients usually present to the anaesthetist before tumour disease surgery, but they are also candidates for elective operations (e.g. hernia repair) and urgent/emergency surgery (e.g. trauma, fractures and ileus). Chemotherapeutic agents given to these patients are potentially noxious, can affect the conduct of anaesthesia and, furthermore, may aggravate the patient's condition. In this review the most commonly used cytostatic drug regimens and their common side-effects are listed. Some preclinical studies on anaesthetic and cytostatic drug metabolism and interactions are emphasized, as well as clinically relevant perioperative alterations that may affect anaesthetic management in cancer patients. An anaesthetist may have to modify a routine anaesthetic regimen in cancer patients especially if anticancer chemotherapeutics were given. Clinically silent toxic drug effects may become apparent during operation, trauma or in the early postoperative course in such patients. Altered reactions to commonly used anaesthetics in patients receiving chemotherapeutics and an impaired stress reaction may occur in such patients. Special attention must be drawn to protection against opportunistic infections.

Oral health care for the cancer patient

Orofacial complications are common after radiotherapy to the head and neck, and after chemotherapy for malignant disease. Mucositis is the most frequent and often most distressing complication, but adverse reactions can affect all other orofacial tissues. This paper discusses the aetiopathogenesis and current means available for preventing, ameliorating and treating these complications, as well as indicating research directions.

Chemotherapy-associated oral mucosal lesions in patients with leukaemia or lymphoma

In order to determine the incidence rate of oral lesions associated with chemotherapy, as well as well as its association with clinical and laboratory parameters and potential risk factors, 50 in-patients with non-Hodgkin's lymphoma or leukaemia under chemotherapy were followed from January 1993 to May 1994. Basal and weekly oral examinations were performed. Clinical and laboratory data were registered. Wilcoxon's rank sum test, chi square test, univariate and multivariate logistic regression analyses were used, 36 individuals with leukaemia and 14 with non-Hodgkin's lymphoma were followed for 158 weeks; mean age was 33 years (range 15-85). Oral lesion incidence rate was 45/100 patients-week. Exfoliative cheilitis and infections (herpes and candidosis) were the most common oral complications, followed by haemorrhagic lesions and mucositis. Haemorrhagic lesions correlated with thrombocytopenia (RR = 30.5). Etoposide administration (RR = 8.6), alkylating agents (RR = 15.6), a prior course of chemotherapy (RR = 23.2) and neutropenia (RR = 4.16) were predictors of mucositis. Oral lesions were a common complication in this study, and a possible association of mucositis with several factors is suggested.

Effect of anticancer drugs on patients with and without initially reduced saliva flow

We reported earlier that despite the well-known cytolytic effect of anticancer drugs, mean stimulated salivary flow rates were not significantly affected during a 12-month follow-up of patients undergoing treatment for lymphomas (Laine et al. Oral Oncol, Eur J Cancer 1992, 28B, 125-128). Therefore, we set out to investigate in more detail the flow rates and composition of salivas in these patients, but now grouped according to their initial flow rate values, which had been assessed before the start of treatment. 49 patients of the original material (30 men and 19 women, mean age 49.9 years) were divided into hyposalivation and normal flow rate groups, according to their baseline values. Stimulated saliva flow > or = 0.8 ml/min was regarded as the limit for a normal flow rate. 11 patients were found to have reduced flow at baseline (hyposalivation group), while 38 patients had normal flow rate. Analysis of repeated saliva samples taken during the 12-month follow-up showed that flow rates remained significantly lower in the hyposalivation group compared with those of the other group (P < 0.001). Further, the concentrations of total protein, albumin, lysozyme, amylase, IgG, IgA and IgM were, and remained, all significantly higher in patients of the hyposalivation group. Counts for salivary mutans streptococci and yeasts were higher and remained significantly so among patients with hyposalivation than among those with normal flow rate while lactobacilli counts were higher in patients with normal initial flow rate.(ABSTRACT TRUNCATED AT 250 WORDS)